Readmission Reduction as a Hospital Quality Measure: Time to Move on to More Pressing Concerns?

The authors of this Viewpoint argue that the focus on hospital readmission rates as a measure of quality during the past decade, although undoubtedly leading to some improvements in care, has had minimal demonstrable benefit and has even distracted clinicians and health system leaders from other crucial quality concerns.

Standardized hospital management of pediatric diabetic ketoacidosis reduces frequency of low blood glucose episodes.

OBJECTIVE: In patients treated for DKA, decrease the rate of visits experiencing one or more BG < 80 mg/dl by 10% within 24 months. RESEARCH DESIGN AND METHODS: Plan-do-study-act cycles tested interventions linked to key drivers including: standardized DKA guidelines incorporating a two-bag fluid system, efficient ordering process, and care team education. Inclusion criterion: treatment for DKA with a bicarbonate value (HCO3 ) <15 mEq/L. PRIMARY OUTCOME: the percent of patient visits experiencing a BG < 80 mg/dl while undergoing treatment for DKA. Process measures included: order panel and order set utilization rates. Balancing measures included: emergency department and hospital lengths of stay, time to acidosis resolution (time to HCO3 ≥ 17 mEq/L), and admission rates. Outcomes were analyzed using statistical process control charts. RESULTS: From January 2017 through May 2021, our institution treated 288 different patients during 557 visits for suspected DKA. Following our interventions, the overall percent of patient visits for DKA with a BG < 80 mg/dl improved from 32% to 5%. The team did see small improvements in emergency department and hospital lengths of stay; otherwise, there was no significant change in our balancing measures. CONCLUSIONS: Use of quality improvement methodology and standardized DKA management resulted in a significant reduction of BG < 80 mg/dl in patients treated for DKA.

Interventions to Improve Communication at Hospital Discharge and Rates of Readmission: A Systematic Review and Meta-analysis.

Importance: Shortcomings in the education of patients at hospital discharge are associated with higher risks for treatment failure and hospital readmission. Whether improving communication at discharge through specific interventions has an association with patient-relevant outcomes remains unclear. Objective: To conduct a systematic review and meta-analysis on the association of communication interventions at hospital discharge with readmission rates and other patient-relevant outcomes. Data Sources: PubMed, EMBASE, PsycINFO, and CINAHL were systematically searched from the inception of each database to February 28, 2021. Study Selection: Randomized clinical trials that randomized patients to receiving a discharge communication intervention or a control group were included. Data Extraction and Synthesis: Two independent reviewers extracted data on outcomes and trial and patient characteristics. Risk of bias was assessed using the Cochrane Risk of Bias Tool. Data were pooled using a random-effects model, and risk ratios (RRs) with corresponding 95% CIs are reported. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Main Outcomes and Measures: The primary outcome was hospital readmission, and secondary outcomes included adherence to treatment regimen, patient satisfaction, mortality, and emergency department reattendance 30 days after hospital discharge. Results: We included 60 randomized clinical trials with a total of 16 070 patients for the qualitative synthesis and 19 trials with a total of 3953 patients for the quantitative synthesis of the primary outcome. Of these, 11 trials had low risk of bias, 6 trials had high risk of bias, and 2 trials had unclear risk of bias. Communication interventions at discharge were significantly associated with lower readmission rates (179 of 1959 patients [9.1%] in intervention groups vs 270 of 1994 patients [13.5%] in control groups; RR, 0.69; 95% CI, 0.56-0.84), higher adherence to treatment regimen (1729 of 2009 patients [86.1%] in intervention groups vs 1599 of 2024 patients [79.0%] in control groups; RR, 1.24; 95% CI, 1.13-1.37), and higher patient satisfaction (1187 of 1949 patients [60.9%] in intervention groups vs 991 of 2002 patients [49.5%] in control groups; RR, 1.41; 95% CI, 1.20-1.66). Conclusions and Relevance: These findings suggest that communication interventions at discharge are significantly associated with fewer hospital readmissions, higher treatment adherence, and higher patient satisfaction and thus are important to facilitate the transition of care.

Evaluation of the Implementation of Multiple Enhanced Recovery After Surgery Pathways Across a Provincial Health Care System in Alberta, Canada.

Importance: Engaging multidisciplinary care teams in surgical practice is important for the improvement of surgical outcomes. Objective: To evaluate the association of multiple Enhanced Recovery After Surgery (ERAS) pathways with ERAS guideline adherence and outcomes. Design, Setting, and Participants: This quality improvement study compared a pre-ERAS cohort (2013-2017) with a post-ERAS cohort (2014-2018). All patients were from Alberta Health Services in Alberta, Canada, and had available ERAS and up to 1-year postsurgery administrative data. Data collected included age, sex, body mass index, tobacco and alcohol use, diabetes, comorbidity index, and surgical characteristics. Data analysis was performed from May 7, 2020, to February 1, 2021. Interventions: Implementation of 5 ERAS pathways (colorectal, liver, pancreas, gynecologic oncology, and radical cystectomy) across 9 sites. Main Outcomes and Measures: Adherence to ERAS guidelines was measured by the percentage of patients whose care met the common ERAS pathway care element criteria. Surgical procedures were grouped by complexity; complications were classified by severity. Outcome measures for the pre-post-ERAS cohorts included length of stay (LOS), readmission, complications, and mortality. Results: A total of 7757 patients participated in the study, including 984 in the pre-ERAS cohort (median [interquartile range] age, 62 [53-71] years; 526 [53.5%] female) and 6773 in the post-ERAS cohort (median [interquartile range] age, 62 [53-71] years; 3470 [51.2%] male). In the total cohort, care-element adherence improved from 52% to 76% (P < .001), no significant differences were found in serious complications (from 6.2% to 4.9%; P = .08) or 30-day mortality (from 0.71% to 0.93%; P = .50), 1-year mortality decreased from 7.1% to 4.6% (P < .001), mean (SD) LOS decreased from 9.4 (7.0) to 7.8 (5.0) days (P < .001), and 30-day readmission rates were unchanged (from 13.4% to 11.7%; P = .12). After adjustment for patient characteristics, the LOS mean difference decreased 0.71 days (95% CI, -1.13 to -0.29 days; P < .001), with no significant differences in adjusted 30-day readmission (-3.5%; 95% CI, -22.7% to 20.4%; P = .75), serious complications (1.3%; 95% CI, -26.2% to 39.0%; P = .94), or mortality (30-day mortality: 42% [95% CI, -35.4% to 212.3%]; P = .38; 1-year mortality: 8% [95% CI, -20.5% to 46.8%]; P = .62). The adjusted 1-year readmission rate was -15.6% (95% CI, -27.7% to -1.5%; P = .03) in favor of ERAS, and readmission LOS was shorter by 1.7 days (95% CI, -3.3 to -0.1 days; P = .04). Conclusions and Relevance: The results of this quality improvement study suggest that implementation of ERAS across multiple pathways may improve health care practitioner adherence to ERAS guidelines, LOS, and readmission rates at a system level.

The Role of Social Determinates of Health in Discharge Practices.

Major risks associated with inadequate discharge preparation and execution include medication errors, adverse drug events, and hospital readmissions. Nurses must develop pertinent skills to assess how the social environment impacts patients' likelihood of a safe and healthy transition back into the community as they prepare patients for discharge. Recognition and consideration of social determinants of health are critical to minimizing health disparities, enhancing health equity and supporting positive patient outcomes. Examples of strategies for enhanced discharge practices include implicit bias assessment and training, screening for food insecurity, and assessment for quality referral sources.

Association Between the Physician Quality Score in the Merit-Based Incentive Payment System and Hospital Performance in Hospital Compare in the First Year of the Program.

Importance: The scientific validity of the Merit-Based Incentive Payment System (MIPS) quality score as a measure of hospital-level patient outcomes is unknown. Objective: To examine whether better physician performance on the MIPS quality score is associated with better hospital outcomes. Design, Setting, and Participants: This cross-sectional study of 38 830 physicians used data from the Centers for Medicare & Medicaid Services (CMS) Physician Compare (2017) merged with CMS Hospital Compare data. Data analysis was conducted from September to November 2020. Main Outcomes and Measures: Linear regression was used to examine the association between physician MIPS quality scores aggregated at the hospital level and hospitalwide measures of (1) postoperative complications, (2) failure to rescue, (3) individual postoperative complications, and (4) readmissions. Results: The study cohort of 38 830 clinicians (5198 [14.6%] women; 12 103 [31.6%] with 11-20 years in practice) included 6580 (17.2%) general surgeons, 8978 (23.4%) orthopedic surgeons, 1617 (4.2%) vascular surgeons, 582 (1.5%) cardiac surgeons, 904 (2.4%) thoracic surgeons, 18 149 (47.4%) anesthesiologists, and 1520 (4.0%) intensivists at 3055 hospitals. The MIPS quality score was not associated with the hospital composite rate of postoperative complications. MIPS quality scores for vascular surgeons in the 11th to 25th percentile, compared with those in the 51st to 100th percentile, were associated with a 0.55-percentage point higher hospital rate of failure to rescue (95% CI, 0.06-1.04 percentage points; P = .03). MIPS quality scores for cardiac surgeons in the 1st to 10th percentile, compared with those in the 51st to 100th percentile, were associated with a 0.41-percentage point higher hospital coronary artery bypass graft (CABG) mortality rate (95% CI, 0.10-0.71 percentage points; P = .01). MIPS quality scores for cardiac surgeons in the 1st to 10th percentile and 11th to 25th percentile, compared with those in the 51st to 100th percentile, were associated with 0.65-percentage point (95% CI, 0.013-1.16 percentage points; P = .02) and 0.48-percentage point (95% CI, 0.07-0.90 percentage points; P = .02) higher hospital CABG readmission rates, respectively. Conclusions and Relevance: In this study, better performance on the physician MIPS quality score was associated with better hospital surgical outcomes for some physician specialties during the first year of MIPS.

Opening Pandora's Box: From Readmissions to Transitional Care Patient-Centered Outcome Measures.

BACKGROUND: Measuring the effectiveness of transitional care interventions has historically relied on health care utilization as the primary outcome. Although the Care Transitions Measure was the first outcome measure specifically developed for transitional care, its applicability beyond the hospital-to-home transition is limited. There is a need for patient-centered outcome measures (PCOMs) to be developed for transitional care settings (ie, TC-PCOMs) to ensure that outcomes are both meaningful to patients and relevant to the particular care transition. The overall objective of this paper is to describe the opportunities and challenges of integrating TC-PCOMs into research and practice. METHODS AND RESULTS: This narrative review was conducted by members of the Patient-Centered Outcomes Research Institute (PCORI) Transitional Care Evidence to Action Network. We define TC-PCOMs as outcomes that matter to patients because they account for their individual experiences, concerns, preferences, needs, and values during the transition period. The cardinal features of TC-PCOMs should be that they are developed following direct input from patients and stakeholders and reflect their lived experience during the transition in question. Although few TC-PCOMs are currently available, existing patient-reported outcome measures could be adapted to become TC-PCOMs if they incorporated input from patients and stakeholders and are validated for the relevant care transition. CONCLUSION: Establishing validated TC-PCOMs is crucial for measuring the responsiveness of transitional care interventions and optimizing care that is meaningful to patients.

Obesity in Inflammatory Bowel Disease Is Associated with Early Readmissions Characterised by an Increased Systems and Patient-level Burden.

BACKGROUND AND AIMS: Rates of obesity are rising in patients with inflammatory bowel disease [IBD]. We conducted a US population-based study to determine the effects of obesity on outcomes in hospitalised patients with IBD. METHODS: We searched the Nationwide Readmissions Database 2016-2017 to identify all adult patients hospitalised for IBD, using ICD-10 codes. We compared obese (body mass index [BMI] ≥ 30) vs non-obese [BMI < 30] patients with IBD to evaluate the independent effects of obesity on readmission, mortality, and other hospital outcomes. Multivariate regression and propensity matching were performed. RESULTS: We identified 143 190 patients with IBD, of whom 9.1% were obese. Obesity was independently associated with higher all-cause readmission at 30 days {18% vs 13% (adjusted odds ratio [aOR] 1.16, p = 0.005)} and 90 days (29% vs 21% [aOR 1.27, p < 0.0001]), as compared with non-obese patients, with similar findings upon a propensity-matched sensitivity analysis. Obese and non-obese patients had similar risks of mortality on index admission [0.24% vs 0.31%, p = 0.18] and readmission [1.5% vs 1.8% p = 0.3]. Obese patients had longer [5.3 vs 4.9 days] and more expensive [USD12,195 vs USD11,154] hospitalisations on index admission. Obesity did not affect the risk of intestinal surgery or bowel obstruction. Compared with index admissions, readmissions were characterised by increased mortality [6-fold], health care use, and bowel obstruction [3-fold] [all p < 0.0001]. CONCLUSIONS: Obesity in IBD appears to be associated with increased early readmission, characterised by a higher burden, despite the introduction of weight-based therapeutics. Prevention of obesity should be a focus in the treatment of IBD to decrease readmission and health care burden.

Association of Neurosurgical Work Relative Value Units with Objective Markers of Operative Complexity.

OBJECTIVE: Relative value units (RVUs) form the backbone of health care service reimbursement calculation in the United States. However, it remains unclear how well RVUs align with objective measures of procedural complexity within neurosurgery. METHODS: The 2018 American College of Surgeons National Surgical Quality Improvement Program database was queried for neurosurgical procedures with >50 patients, using Current Procedural Terminology (CPT) codes. Length of stay (LOS), operative time, mortality, and readmission and reoperation rates were collected for each code and a univariate correlation analysis was performed, with significant predictors entered into a multivariate logistic regression model, which generated predicted work RVUs, which were compared with actual RVUs to identify undervalued and overvalued procedures. RESULTS: Among 64 CPT codes, LOS, operative time, mortality, readmission, and reoperation were significant independent predictors of work RVUs and together explained 76% of RVU variance in a multivariate model (R2 = 0.76). Using a difference of >1.5 standard deviations from the mean, procedures associated with greater than predicted RVU included surgery for intracranial carotid circulation aneurysms (CPTs 61697 and 61700; residual RVU = 12.94 and 15.07, respectively), and infratemporal preauricular approaches to middle cranial fossa (CPT 61590; residual RVU = 15.39). Conversely, laminectomy/foraminotomy for decompression of additional spinal cord, cauda equina, and/or nerve root segments (CPT 63048; residual RVU = -21.30), transtemporal craniotomy for cerebellopontine angle tumor resection (CPT 61526; residual RVU = -9.95), and brachial plexus neuroplasty (CPT 64713; residual RVU = -11.29) were associated with lower than predicted RVU. CONCLUSIONS: Work RVUs for neurosurgical procedures are largely predictive of objective measures of surgical complexity, with few notable exceptions.

National Landscape of Unplanned 30-Day Readmission Rates for Acute Non-hemorrhagic Diverticulitis: Insight from National Readmission Database.

BACKGROUND: Early readmissions are an important indicator of the quality of care. Limited data exist describing hospital readmissions in acute diverticulitis. The study aimed to describe unplanned, 30-day readmissions among adult acute diverticulitis patients and to assess readmission predictors. METHODS: We analyzed the 2013 and 2014 United States National Readmission Database and identified acute diverticulitis admissions using administrative codes in adult patients older than 18 years of age. Our primary outcome was a 30-day, unplanned readmission rate. We used Chi-square tests, t tests, and Wilcoxon rank-sum tests for descriptive analyses and survey logistic regression to calculate adjusted odds ratios (aORs) and 95% confidence intervals for associations with readmissions adjusting for confounders. RESULTS: In the cohort of 364,511 hospitalizations with acute diverticulitis, as the primary diagnosis on index admission, 31,420 (8.6%) had at least one unplanned 30-day readmission. Sixty percent of the readmissions occurred within the first 2 weeks of the index admission. The most common reasons for unplanned 30-day readmission were due to diverticulitis of the colon (41.5%), postoperative infection (4.2%), septicemia (3.6%), intestinal infection due to Clostridium difficile (3%), and other digestive system complications such bleeding or fistula (2.8%). Multivariable analysis showed advance age (> 75 years), discharge against medical advice, comorbidities (renal failure, coronary artery disease, atrial fibrillation, congestive heart failure, hypertension, diabetes, obesity, weight loss, chronic lung disease, malignancy), blood transfusion, Medicare and Medicaid insurance, and increased length of stay (> 3 days) were associated with significantly higher odds for readmission. Patients who have undergone abdominal surgery during index admission were 31% less likely to get readmitted. CONCLUSIONS: On a national level, 1 in 11 hospitalizations for acute diverticulitis was followed by unplanned readmission within 30 days with most admissions occurring in the first 2 weeks. Multiple modifiable and non-modifiable factors influencing readmission rates were noted. Further studies should examine if strategies that address these predictors can decrease readmissions.

Implementation of a Disease Management Program in Adult Patients With Heart Failure.

BACKGROUND: Approximately 5.7 million people in the United States are diagnosed and living with heart failure (HF), with projected prevalence rates to increase 46% by 2030. Heart failure leads hospital admissions in the United States for individuals 65 years or older, with many acute exacerbation admissions resulting from a lack of medication management, poor patient treatment plan adherence, and lack of appropriate follow-up within the health care system. In 2017, the 30-day HF readmission rate at the facility of implementation was 27%, 3% higher than the national average and, more specifically, 18.5% for the cardiac care unit (CCU). OBJECTIVE: The aim of this study was to develop an HF disease management program to reduce 30-day readmission rates for HF patients through the implementation of a structured program including self-care education utilizing the teach-back method, multimodal medication reconciliation, multidisciplinary consultation, telephone follow-up within 48-72 hr of discharge, and follow-up visit within 7-10 days of discharge. PRIMARY PRACTICE SETTING: The implementation of the disease management program took place at a major military treatment facility in the continental United States. The facility is a teaching facility housing a 272-bed multispecialty hospital and an ambulatory complex. The implementation took place on the CCU, the primary unit for cardiac admissions, with approximately 30 admissions a month for a primary diagnosis of HF. METHODOLOGY AND SAMPLE: In August 2018, a multidisciplinary disease management program was implemented to include patient education utilizing the teach-back method, multimodal medication reconciliation, multidisciplinary consultation, telephone follow-up within 48-72 hr of discharge, and follow-up visit within 7-10 days of discharge. Data were collected and analyzed for 90 days and compared with retrospective data from 2017. FINDINGS: Participants in the disease management program had a statistically significant improvement (p < .001) in the hospital readmission rate. The overall 30-day readmission rate decreased from 27% to 10.2% during the implementation period, a decrease of 38%. Ninety-three percent of the patients completed the self-care education, and telephone follow-up was successfully achieved with 96% of these patients. Only 4 patients in the HF disease management program experienced readmission within 30 days. Patients and caregivers reported increased satisfaction with their care due to the disease management program and increased follow-up with care. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: The findings of this innovation suggest that a multidisciplinary disease management program can reduce avoidable 30-day readmissions. The program improved patient follow-up and decreased follow-up appointment no-shows. Multiple participants expressed increased patient satisfaction. The program supports the need for coordinated, interdisciplinary disease management to improve the quality of life of those affected by HF and improve the use of resources to reduce the overall health care burden. Case management is critical to the organized care of HF patients due to the complex, individualized care to achieve optimum patient outcomes.

Implementing a Nurse Discharge Navigator: Reducing 30-Day Readmissions for Heart Failure and Sepsis Populations.

PURPOSE/OBJECTIVES: The purpose of this quality improvement project was to evaluate the impact of a nurse discharge navigator on reducing 30-day readmissions for the heart failure and sepsis populations. PRIMARY PRACTICE SETTING: The 238-bed community hospital in central Virginia is part of a health care system that encompasses 13 acute care facilities. METHODOLOGY AND SAMPLE: The aim of this project was to identify, implement, and evaluate the transition of care of high-risk readmission patients from January 2019 to April 2019. Inclusion criteria included patients who were 55 years and older, English speaking, diagnosed with heart failure and/or sepsis, discharged to home with or without home health, and/or consults received from case management and social services. Forty-one potential participants were identified with 28 consented. Readmission data were collected pre- and postintervention. The pre-/postanalysis consisted of descriptive statistics, readmission rates, and cost avoidance. RESULTS: Out of the 28 participants, 7 participants were readmitted within 30 days. The heart failure readmission rates during the project implementation were as follows: January 24.05%, February 20%, March 19.75%, and April 11.11%. After the project completion the readmission rates were 22.97% for May and 26.03% for June, respectively. The potential cost avoidance with sustained gain from the project is $405,316.00. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: This project demonstrated that a discharge navigator had an effect on 30-day readmissions for high-risk heart failure and sepsis populations, as evident by a steady decline in overall heart failure readmission rate during project implementation. The sepsis population needs further research. The discharge navigator project added to the body of knowledge for comprehensive discharge planning, coordination, and education that is needed for these types of patient populations that have a great deal of medical complexity.

Substantial hospital level variation in all-cause readmission rates among medicare beneficiaries with serious mental illness.

BACKGROUND: Patients with serious mental illness (i.e., SMI; bipolar disorder, major depressive disorder, and schizophrenia) are at increased risk of readmission, yet little is known about the extent to which readmission rates among these patients vary across hospitals. The purpose of this study was to examine the variation across hospitals in readmissions for patients with SMI and differences in the characteristics of hospitals with the highest and lowest adjusted readmission rates. METHODS: We conducted a cross-sectional analysis of pooled inpatient claims from 2013-2016. Mixed logit models with hospital random effects were used to estimate the hospital-level variance. The sample included patients with SMI from a 5% sample of fee-for-service Medicare beneficiaries. RESULTS: We identified 2066 hospitals with at least 30 index admissions for Medicare beneficiaries with SMI. In multivariate analyses, factors most strongly associated with increased risk of readmission included substance use disorder (OR 2.311; p < 0.001) and end stage renal disease (OR 2.024; p < 0.001). Unadjusted readmission for hospitals at the 5th and 95th percentiles of performance were 7.05% and 15.24%, respectively, constituting an 8.2% difference. Adjusting for patient and community characteristics reduced the spread in readmission rates between the 5th and 95th percentiles of hospitals by 1.0% (i.e. to 7.2%). Hospitals in the lowest vs. highest quintiles of adjusted readmission rates were more likely to be teaching hospitals (11.1% vs. 16.7%; p < 0.05) and located in the South (37.7% vs. 40.4%) or Midwest (19.8% vs. 30.0%; p < 0.001 for region differences). CONCLUSIONS: There is substantial hospital-level variation in readmission rates among patients with serious mental illness, even after adjusting for patient and community characteristics. This has implications for policy guiding investment in hospital-based services and community resources, to improve transitions of care for patients with SMI.

Urgencias psiquiátricas infanto-juveniles: ¿Quiénes son los hiperfrecuentadores? / Psychiatric Emergencies in Children and Adolescents: Who are the Frequent Attenders?

INTRODUCCIÓN: La hiperfrecuentación en los servicios de urgencias impacta en la calidad asistencial y el consumo de recursos. Los datos disponibles en relación al colectivo infanto-juvenil hiperfrecuentador en urgencias de psiquiatría son escasos, a pesar del aumento de visitas en los últimos años. OBJETIVO: Caracterizar la hiperfrecuentación infanto-juvenil de urgencias de psiquiatría de un hospital terciario durante el año 2017. MÉTODOS: Estudio observacional retrospectivo, diseño caso-control. Se seleccionaron todos los usuarios menores de edad visitados en nuestras urgencias de psiquiatría y de nuestro sector durante el 2017. Se obtuvieron datos sociodemográficos y clínicos mediante explotación de datos asistenciales y revisión de historias clínicas. La hiperfrecuentación se estableció como ≥5 visitas/año. Se realizó un análisis descriptivo univariado y uno comparativo bivariado entre personas hiperfrecuentadoras y no hiperfrecuentadoras. RESULTADOS: La muestra incluyó 550 personas menores de edad, siendo hiperfrecuentadoras un 3,8% (n=21). Las hiperfrecuentadoras fueron de nacionalidad extranjera en mayor proporción (28,6% vs 13,1%, p = 0,04), sin otras diferencias significativas. Entre el colectivo hiperfrecuentador, el trastorno de conducta fue el diagnóstico principal más prevalente (33,3%), recibía tratamiento psicofarmacológico habitual el 100% (antipsicóticos un 95,2%) y existían factores de vulnerabilidad social en una elevada proporción (distocia sociofamiliar 61,8%, institucionalización 48%). CONCLUSIONES: La hiperfrecuentación infanto-juvenil en urgencias de psiquiatría es una realidad. Se trata de una población socialmente vulnerable, altamente medicada y en la que destaca la problemática conductual. Este colectivo requiere de una atención compleja y multidisciplinar, donde los recursos de soporte social juegan un papel clave

INTRODUCTION: Frequent attenders to the emergency department affect quality of care and imply resource overuse. Data regarding child and adolescent psychiatric frequent attendance to the emergency department is scarce, although their number of visits is growing. OBJECTIVE: To characterize child and adolescent frequent attenders in the psychiatric emergency department of Hospital Clínic de Barcelona during the year 2017. METHODS: Retrospective observational study, case-control design. We selected all minors who attended our psychiatric emergency department in 2017 that belonged to our catchment area. We collected sociodemographic and clinical data through automatic extraction and manual review of electronic medical records. Frequent attendance was established as ≥5 visits/year. We performed a descriptive analysis of frequent attenders and a bivariate analysis comparing frequent attenders versus non-frequent attenders. RESULTS: Our sample included 550 children and adolescents, of which 3.8% (n=21) were frequent attenders. There were significantly more foreigners among frequent attenders (28.6% vs 13.1%, p = 0.04), without other differences between groups. Among frequent attenders, conduct disorders were the most prevalent main diagnoses (33.3%), all had at least one psychotropic medication prescribed (antipsychotics in 95.2%) and social vulnerability factors were present for most of them (family conflict in 61.8%, 48% living in residential care institutions). CONCLUSIONS: Child and adolescent frequent attendance to the psychiatric emergency department is a reality. They are a socially vulnerable and highly medicated subgroup, with a preponderance of conduct problems. They are in need of a comprehensive and multidisciplinary approach, were social services are a key feature

A nurse practitioner-led effort to reduce 30-day heart failure readmissions.

BACKGROUND: Heart failure (HF) affects over 6.5 million Americans and is the leading reason for hospital admissions in patients over the age of 65. Readmission rates within 30 days are 21.4% nationally, and 12% of those are likely preventable. Veterans are especially vulnerable to developing cardiac diseases requiring hospitalization and subsequent readmission. LOCAL PROBLEM: The Southern Arizona Veterans Administration Health Care System has over 5,600 patients diagnosed with HF and a 30-day readmission rate of 21.65%. The aim of this quality improvement project was to reduce 30-day all-cause readmissions by 1% over 8 weeks. METHODS: To reduce HF readmissions, the plan-do-study-act rapid-cycle method of quality improvement was used. INTERVENTIONS: A dedicated multidisciplinary HF clinic was formed with a cardiology nurse practitioner, clinical pharmacists, and a dietician. A veteran-centered shared decision-making tool for setting self-care goals was implemented. RESULTS: The readmission rate of patients seen in the multidisciplinary clinic (n = 33) was reduced by 0.2%. The percentage of veterans seen within 14 days increased from 30% to 54.5%. The average number of days between discharge and cardiology follow-up improved from 45 to 19 days. Veterans were able to set at least one self-care goal 87% of the time. Patient satisfaction with the multidisciplinary clinic was high at 93%. CONCLUSIONS: Implementing a dedicated, multidisciplinary HF clinic reduced readmissions, improved timeliness of visits, and was well received. Use of a veteran-centered patient engagement tool resulted in more veterans setting self-care goals.

Interventions Used for Reducing Readmissions for Surgical Site Infections.

This article examines what hospitals can do to reduce readmissions for surgical site infections (SSI). Realizing that CMS does not pay the hospital for readmissions due to SSI, strategies must be put into place to reduce the number of readmissions. The analysis here will examine what has been done in the hospital, then, ways to assess each patients risk for SSI upon leaving the hospital. Finally, providing some interventions for reducing SSIs. Introducing the concept of "visiting practitioner."

Outpatient Versus Inpatient Posterior Lumbar Fusion for Low-Risk Patients: An Analysis of Thirty-Day Outcomes From the National Surgical Quality Improvement Program.

BACKGROUND: Outpatient spine surgery has been increasingly used recently owing to its perceived cost benefits and its ability to offset the volume from the inpatient setting. However, the 30-day outcomes of outpatient posterior lumbar fusion (PLF) for low-risk patients have not been extensively studied. In the present study, we assessed the 30-day outcomes of outpatient PLF surgery for low-risk patients using a national surgical quality registry. METHODS: For the present study, we queried the American College of Surgeons National Surgical Quality Improvement Program for patients who had undergone PLF from 2009 to 2016. Only patients with an American Society of Anesthesiologists grade of 1-2 were included. The 30-day outcomes, including any complications, readmissions, and reoperations, were studied using multivariable logistic regression after adjustment for an array of patient-specific factors. RESULTS: A total of 29,830 cases were identified. Of these 29,830 cases, 1016 (3.4%) had been performed as outpatient cases and 28,814 (96.6%) as inpatient. After adjusting for an array of patient-specific factors, we did not find any significant association between the procedure setting and complication rate (odds ratio [OR], 0.8; 95% confidence interval [CI], 0.6-1.1; P = 0.15) or 30-day readmission rate (OR, 0.9; 95% CI, 0.6-1.4; P = 0.76). Patients undergoing outpatient PLF were more likely to have required a 30-day reoperation (OR, 1.6; 95% CI, 1.1-2.4; P = 0.02). CONCLUSION: Our results have demonstrated that the 30-day outcomes of patients who have undergone outpatient PLF might be comparable to those of patients who have undergone PLF in an inpatient setting. However, outpatient surgery might be associated with a greater overall reoperation rate.

Greater Changes in Drug Burden Index (DBI) during Hospitalization and Increased 30-Day Readmission Rates among Older In-Hospital Fallers.

A higher drug burden index (DBI) is known to be associated with pre-admission falls leading to hospitalization. We investigated whether a mean difference in DBI (ΔDBI) between the events of in-hospital falls and hospital admission was associated with 30-day readmission in 113 patients ≥50 years who fell during their hospital stays between 2007 and 2014. A greater ΔDBI (≥0.09) was positively associated with higher 30-day readmission rates (incident rate ratio: 2.02; 95% confidence interval: 1.49-2.74). An effort to keep DBI low may thus decrease 30-day readmissions for older in-hospital fallers.